Physician'S Assessment And Initial Order Form - Helping Hands Adult Day Services

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PHYSICIAN’S ASSESSMENT AND INITIAL ORDER FORM
Date: _______ / _______ /_______
Patient Name __________________________________________________________________________ Date of Birth _______ / _______ /_______
Baseline Data: Weight: _______ Height: _______ BP: _________ Temp: _______ Pulse: ________
Resp: _______
Primary Diagnosis: _____________________________________________________________________________________________________________
Secondary Diagnosis: __________________________________________________________________________________________________________
NUMBER OF DAYS CLIENT MAY ATTEND:
5
4
3
2
(Please circle one)
Significant Past Medical/Surgical History:
System
Normal
Abnormal
History
Present Condition
Cardiovascular System
Metabolic System
Respiratory System
Nervous System
Endocrine System
Digestive System
Reproductive System
Musculoskeletal System
Urological System
Vision
Hearing
Other
PATIENT MUST BE CERTIFIED FREE FROM TUBERCULOSIS
Skin test or Chest x-ray (circle one)
Date: _______ / _______ / _______ Result: ___________________________________
Is the patient free from Infectious Disease?
Yes ______
No _______
Is the patient oriented to:
Person _______ Place _______
Time _______
Is there memory loss or deficit evident with?
Recent Memory:
recall _______
recognition _______
Remote Memory:
recall _______
recognition _______
Do any of the following apply?
Depression: Yes _____ No _____ Anxiety Disorder: Yes _____ No _____ Hostility/Combativeness: Yes _____ No ____
Is assistance required with:
ADLs: Yes _____ No _____
Mobility: Yes _____ No _____
Communication: Yes _____ No _____
Assistive Devices: Wheelchair _____
Cane _____
Walker _____
Is patient contenent? Bowel: Yes _______ No _______
Bladder: Yes _______ No _______
Any history of seizures?
Yes _______ No _______
RECOMMENDED DIET: Regular _____
Regular, NAS _____
Diabetic _____ Other _____

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